Cardiff and Vale University Health Board
NHS / Health Body
Action Taken
The Health Board is expanding falls prevention training, undertaking improvement work regarding bedrails and auditing their use, updating the enhanced supervision framework and developing a new policy, and piloting education programmes for staff. (AI summary)
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Dear Ms Knight
I am writing in response to the report to prevent future deaths, issued following the inquest into the death of Mr Colin Colley in October 2023. I would also like to take this opportunity to offer my sincere condolences to Mr Colley’s family. As a Health Board we would welcome the opportunity to meet with them and discuss the actions that have been taken to mitigate the risk of a future death occurring in similar circumstances.
In your report, you raised concerns regarding the confidence of our qualified nursing staff, healthcare assistants, and healthcare support workers in the use and implication of risk assessments around falls, as well as the use and importance of enhanced supervision and related documentation. I have outlined below the significant work that has been undertaken and is ongoing to address these concerns and improve the confidence of our staff in the prevention and management of falls and the use of enhanced supervision.
Falls Prevention and Management
Expanding falls prevention and management training has been a particular focus for the Health Board, with St David’s Hospital serving as an early pilot site. Training sessions were provided to St David’s staff in September, October, and December 2024, with additional dates offered in May and June 2025. To date, 59% of qualified nurses have completed the training. We aim to reach compliance figures of a minimum of 85%. Study days have been booked, and the target compliance figure of 70 should be achievable by July 2025, provided there are no cancellations due to other pressures. The trajectory will be monitored to achieve and maintain in excess of 85% compliance by year end. Eich cyf/Your ref: Ein cyf/Our ref: SR-jb-0525-089 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 029 2183 6010 Executive Headquarters / Pencadlys Gweithredol
Woodland House
Ty Coedtir Maes-y-Coed Road
Ffordd Maes-y-Coed Cardiff
Caerdydd CF14 4HH
CF14 4HH
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
The falls training delivered within the Health Board was developed from a successful programme within Mental Health Services for Older People (MHSOP), which demonstrated a reduction in falls following the training sessions. This training was adapted to ensure suitability for physical health areas by a multidisciplinary team as part of the Dragon’s Heart Institute’s Spread and Scale Academy. A Falls Strategy Lead was recruited in July 2023 to support the coordination of training and other falls- related work.
The rollout of training across the University Health Board (UHB) continues, with positive impacts observed through programme evaluations. Audits have shown a 25% improvement in the completion and quality of the Multifactorial Risk Assessments (MFRAs) following training. Additionally, staff who have undertaken the training have reported increased confidence in completing the MFRA.
The Health Board has also included falls prevention and management training as part of the preceptorship programme for all newly qualified nursing staff and the Health Care Support Worker (HCSW) induction programme.
Significant efforts have been made to ensure a prompt and effective response when a patient falls within our hospitals. This includes the introduction of action cards, which provide easy-to-follow steps and practical information, such as the location of equipment and relevant telephone numbers. At St David’s, we have implemented a new process allowing ward staff to contact the Emergency Unit Consultant or Senior Registrar for support and advice following a patient fall out of hours. This advice is provided via the Consultant Connect system, preventing unnecessary ambulance transfers and offering reassurance and guidance for nursing staff when the patient remains on the ward for monitoring.
A digital version of the MFRA is part of the suite of risk assessments within the Welsh Nursing Care Record (WNCR), which is live across St David’s Hospital. This provides additional data on the completion of the MFRA, which can be used to inform specific areas of focus for falls training. The Health Board has also led a proposal to update the digital MFRA, making it easier for staff to complete and placing a greater focus on actions taken to reduce patients’ falls risks. Compliance with falls guidance and documentation of falls risks is audited via the Tendable platform and feeds into the Health Board’s nursing dashboard.
The significant work undertaken over the last two years has contributed to an updated Health Board procedure for the prevention and management of adult inpatient falls, which is in the final stages of sign-off. We have also developed a staff intranet site containing a wealth of useful information, including electronic copies of the action cards and training videos.
Bedrails
The Health Board has implemented ultra-low beds with integral rails across all general inpatient areas to enhance safety. Bedrail risk assessments are a mandatory part of nursing inpatient risk assessments and are discussed during falls training. It is reinforced during training that bedrail use requires individual assessment, reflecting
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
the patient's function and considering the Mental Capacity Act where the rails may prevent a patient from mobilising from bed without assistance.
A multidisciplinary task and finish group is being established to undertake improvement work regarding bedrails, including auditing their use to inform an updated bedrails procedure. The Health Board will also be represented at the WNCR All-Wales bedrails risk assessment task and finish group, which is tasked with digitising the current paper-based assessment document. This will improve the data available on the use of the assessment and make it easier for nursing staff as it will be alongside other assessments within WNCR.
Enhanced Supervision
Enhanced supervision is used to support people during temporary periods of distress when there is a risk of harm to themselves and/or others. The care provided must be person-centred and in line with the least restrictive principles of the Mental Capacity Act.
Significant work is underway both locally and nationally regarding the use of enhanced supervision.
Since autumn 2023, pilots of education programmes have been delivered to over ninety staff across the Health Board, and educational resources have been developed and are currently being delivered as part of the newly registered nurse preceptorship programme.
Alongside this, a task and finish group is updating the existing enhanced supervision framework and developing a new policy to provide more robust governance around its use. From May 2025, a steering group has been convened, chaired by the Deputy Executive Nurse Director, to take forward this work.
I hope this letter provides reassurance regarding the significant work that has taken place within our organisation since Mr Colley’s sad death.
If there is any further information that would be helpful regarding our improvements to falls prevention and management, the use of bedrails, the use of enhanced supervision, or any other aspect of care provided at St David's Hospital, please do not hesitate to make further contact.
I am writing in response to the report to prevent future deaths, issued following the inquest into the death of Mr Colin Colley in October 2023. I would also like to take this opportunity to offer my sincere condolences to Mr Colley’s family. As a Health Board we would welcome the opportunity to meet with them and discuss the actions that have been taken to mitigate the risk of a future death occurring in similar circumstances.
In your report, you raised concerns regarding the confidence of our qualified nursing staff, healthcare assistants, and healthcare support workers in the use and implication of risk assessments around falls, as well as the use and importance of enhanced supervision and related documentation. I have outlined below the significant work that has been undertaken and is ongoing to address these concerns and improve the confidence of our staff in the prevention and management of falls and the use of enhanced supervision.
Falls Prevention and Management
Expanding falls prevention and management training has been a particular focus for the Health Board, with St David’s Hospital serving as an early pilot site. Training sessions were provided to St David’s staff in September, October, and December 2024, with additional dates offered in May and June 2025. To date, 59% of qualified nurses have completed the training. We aim to reach compliance figures of a minimum of 85%. Study days have been booked, and the target compliance figure of 70 should be achievable by July 2025, provided there are no cancellations due to other pressures. The trajectory will be monitored to achieve and maintain in excess of 85% compliance by year end. Eich cyf/Your ref: Ein cyf/Our ref: SR-jb-0525-089 Welsh Health Telephone Network: Direct Line/Llinell uniongychol: 029 2183 6010 Executive Headquarters / Pencadlys Gweithredol
Woodland House
Ty Coedtir Maes-y-Coed Road
Ffordd Maes-y-Coed Cardiff
Caerdydd CF14 4HH
CF14 4HH
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
The falls training delivered within the Health Board was developed from a successful programme within Mental Health Services for Older People (MHSOP), which demonstrated a reduction in falls following the training sessions. This training was adapted to ensure suitability for physical health areas by a multidisciplinary team as part of the Dragon’s Heart Institute’s Spread and Scale Academy. A Falls Strategy Lead was recruited in July 2023 to support the coordination of training and other falls- related work.
The rollout of training across the University Health Board (UHB) continues, with positive impacts observed through programme evaluations. Audits have shown a 25% improvement in the completion and quality of the Multifactorial Risk Assessments (MFRAs) following training. Additionally, staff who have undertaken the training have reported increased confidence in completing the MFRA.
The Health Board has also included falls prevention and management training as part of the preceptorship programme for all newly qualified nursing staff and the Health Care Support Worker (HCSW) induction programme.
Significant efforts have been made to ensure a prompt and effective response when a patient falls within our hospitals. This includes the introduction of action cards, which provide easy-to-follow steps and practical information, such as the location of equipment and relevant telephone numbers. At St David’s, we have implemented a new process allowing ward staff to contact the Emergency Unit Consultant or Senior Registrar for support and advice following a patient fall out of hours. This advice is provided via the Consultant Connect system, preventing unnecessary ambulance transfers and offering reassurance and guidance for nursing staff when the patient remains on the ward for monitoring.
A digital version of the MFRA is part of the suite of risk assessments within the Welsh Nursing Care Record (WNCR), which is live across St David’s Hospital. This provides additional data on the completion of the MFRA, which can be used to inform specific areas of focus for falls training. The Health Board has also led a proposal to update the digital MFRA, making it easier for staff to complete and placing a greater focus on actions taken to reduce patients’ falls risks. Compliance with falls guidance and documentation of falls risks is audited via the Tendable platform and feeds into the Health Board’s nursing dashboard.
The significant work undertaken over the last two years has contributed to an updated Health Board procedure for the prevention and management of adult inpatient falls, which is in the final stages of sign-off. We have also developed a staff intranet site containing a wealth of useful information, including electronic copies of the action cards and training videos.
Bedrails
The Health Board has implemented ultra-low beds with integral rails across all general inpatient areas to enhance safety. Bedrail risk assessments are a mandatory part of nursing inpatient risk assessments and are discussed during falls training. It is reinforced during training that bedrail use requires individual assessment, reflecting
Bwrdd Iechyd Prifysgol Caerdydd a’r Fro yw enw gweithredol Bwyrdd Iechyd Lleol Prifysgol Caerdydd a’r Fro Cardiff and Vale University Health Board is the operational name of Cardiff and Vale University Local Health Board
Croesawir y Bwrdd ohebiaeth yn Gymraeg neu Saesneg. Sicrhawn byddwn yn cyfathrebu â chi yn eich dewis iaith. Ni fydd gohebu yn Gymraeg yn creu unrhyw oedi The Board welcomes correspondence in Welsh or English. We will ensure that we will communicate in your chosen language. Correspondence in Welsh will not lead to a delay
the patient's function and considering the Mental Capacity Act where the rails may prevent a patient from mobilising from bed without assistance.
A multidisciplinary task and finish group is being established to undertake improvement work regarding bedrails, including auditing their use to inform an updated bedrails procedure. The Health Board will also be represented at the WNCR All-Wales bedrails risk assessment task and finish group, which is tasked with digitising the current paper-based assessment document. This will improve the data available on the use of the assessment and make it easier for nursing staff as it will be alongside other assessments within WNCR.
Enhanced Supervision
Enhanced supervision is used to support people during temporary periods of distress when there is a risk of harm to themselves and/or others. The care provided must be person-centred and in line with the least restrictive principles of the Mental Capacity Act.
Significant work is underway both locally and nationally regarding the use of enhanced supervision.
Since autumn 2023, pilots of education programmes have been delivered to over ninety staff across the Health Board, and educational resources have been developed and are currently being delivered as part of the newly registered nurse preceptorship programme.
Alongside this, a task and finish group is updating the existing enhanced supervision framework and developing a new policy to provide more robust governance around its use. From May 2025, a steering group has been convened, chaired by the Deputy Executive Nurse Director, to take forward this work.
I hope this letter provides reassurance regarding the significant work that has taken place within our organisation since Mr Colley’s sad death.
If there is any further information that would be helpful regarding our improvements to falls prevention and management, the use of bedrails, the use of enhanced supervision, or any other aspect of care provided at St David's Hospital, please do not hesitate to make further contact.